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Patti Atteberry
Excessive cathflo use

Does anyone have any suggestions....we have a patient that has a duel lumen power picc recieving continuous TPN.  We have had to send out cathflo for no blood return several times.  The flushes have been reviewed with nurse and patient, occasionally the line has been positional but repositioning seldom works.  i am wondering if there could be a lipid build up and then blood is collecting allow the cathflo to work for a period of time.  What else do you think i should try.  (we flush with 20ml after TPN)

Thank you

lynncrni
What type of syringe are you

What type of syringe are you using? Traditional syringes are not designed to flush catheters. The volume of displacment in the positive needleless connectors may not be sufficient to overcome both syringe-induced and disconnection reflux. If using a traditional syringe, do not flush all the fluid from the syringe. Leave at least a 0.5 ml so that you will not compress the plunger rod gasket and induce this type of reflux. Also make sure that you are using the correct flushing technique for the type of needleless connector being used. If none of this is the problem, you may not be dealing with a problem inside the catheter lumen at all. This may be a fibrin sheath that is around the extraluminal catheter. Your treatment with alteplase is only reaching the part of the fibrin that is directly at the catheter tip. then it re-grows. In that case a low dose infusion of alteplase may reach the entire pericatheter fibrin.  

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Patti Atteberry
We are using the anti-reflux

We are using the anti-reflux syringes, positive pressure connectors.  The nurse re-evaluated the procedure of flushing with the patient (after I reviewed with her to be sure).  do you have any other information regarding the altepase infusion.  I have not heard of doing this.  I will have to find out about the mirgration and possible x-ray.

Thank you

Patti Atteberry, RN, CRNI
lynncrni
Here is one article about

Here is one article about alteplase infusion with a low dose of 2.5 mg in 50 ml over 3 hours.   

 1.    Santilli J. Fibrin sheaths and central venous catheter occlusions: Diagnosis and management. Techniques in Vascular and Interventional Radiology. 2002;5(2):89-94.

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

momdogz
Have you checked for

Have you checked for catheter migration?  When is the last time you knew where the tip of the catheter was?  Possibly resting against the vein or malpositioned somewhere else?   The radiologists usually don't tell you anything more than "SVC" or "upper SVC" - you'd have to look at the film yourself (e.g. if it's upper SVC and a left sided approach, the tip could be resting/moving up against the vein wall, or tip could be malpositioned elsewhere).  

 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Pam Michael
I have a question that goes

I have a question that goes along with excessive cathflo use.  How many clinicians are using cathflo each time a positive blood flow is not obtained prior to infusion. (I know the recommendation is 2mg may be used twice for each lumen.) 

If CXR shows SVC and 2 hours previous a positive blood flow was obtained, but now you can't get a + blood return. Are you instilling cathflo, after of course trying all the tricks,  ie. coughing, raising the arm, having the patient reposition, etc....?  

Thanks,

 

Lynn, do you have administering information for low dose alteplase infusion?

How much, for how long, etc...?

 

Pam Michael, RN

valoriedunn
When infusing cathflo over

When infusing cathflo over the three hours that Lynn mentioned, do you use a 0.2 micron filter?  Thanks, Valorie

Valorie Dunn,BSN, RN, CRNI, PLNC

ptrn
Is this acute care setting or

Is this acute care setting or home setting?  If home setting, is family/caregiver maintaining the Picc line and changing TPN bag daily?  I would recommend daily flushing of Picc line w/ use of Heparin in between TPN bag change, not sure if that is being done.  What concerns me is that it is known that the line is "positional" and TPN is still running.  Depending on the make up of TPN, osmolarity can be high which can extravasate the tissue....thus being a vesicant.  I would look at catheter placement, as well as catheter tip placement.  Pt. may have Pinch off syndrome or some sort of malpositioning....fibrin sheath.  Cathetergram, CXR are all options... Bottom line, if the TPN is going to be long term, I would suggest catheter replacment.  Hope that helps!! :-)

----Micron filter is used for TPN but not TPA infusions.

ptrn
Is this acute care setting or

Sorry, got trigger happy and pushed save twice.

Nadine Nakazawa
 If there is repeated Cathflo

 If there is repeated Cathflo usage, I'd get a CXR to be sure the catheter tip is deep enough.  Oftentimes repeated occlusion despite successful restoration of patency using Cathflo indicates some other type of problem.  Oftentimes the catheter tip is impinging against the SVC wall mid-SVC  rather than deep in the lower third of the SVC near the CAJ.  That is a mechanical problem and the patient may need to have the tunneled catheter replaced.  I'd be sure you pick a clinician who does a lot of vascular access as a part of their practice as opposed to the clinician who does only the very occasional tunneled CVC.  

Lipids buildup inside the lumen with TPN/lipids occurs slowly over time, and Cathflo would not make a difference in restoring patency.  If you thought it might be a lipid precipitate, try pharmaceutical grade 70% ethanol and instill 1 ml for about an hour.  Ethanol should NOT be used in polyurethane catheters, however.  

It could also be a kink in the subcutaenous tunnel.  

Nadine Nakazawa, RN, BS, OCN, CRNI, VA-BC

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